Ocean Park Healthcare
OCEAN PARK HEALTHCARE in SANTA MONICA, CA — inspection on May 4, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a record review of the Admission Record indicated Resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and unspecified dementia (a progressive state of decline in mental abilities).
During a record review of the Minimum Data Set (MDS - resident assessment tool) dated 4/22/2025, indicated Resident 10's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.
The MDS indicated Resident 10 required moderate assistance to supervision from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).
During a record review of Resident 10's Order Summary Report indicated the following:
i. As of 5/4/2025, there was no physician order for the use of bed siderails.
ii.
Physician's order dated 4/18/2025 indicated, Up on geri-chair for mobility issues due to difficulty seating on upright positioned.
During a record eview of Resident 10's Medical Record as of 5/4/2025, there was no Informed Consent for the use of bed siderails and geri-chair with lap tray.
During a record review of Resident 10's Care Plan (CP) as 5/4/2025, indicated there are no CP developed for the use of bed siderails.
555786
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555786 B.
Wing 05/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Ocean Park Healthcare 2828 Pico Boulevard Santa Monica, CA 90405
During a record review of the MDS dated [DATE], Resident 12's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.
The MDS indicated Resident 12 had an active diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought).
During an interview and observation of Resident 12 on 5/2/2025 at 6:12 p.m., Resident 12 stated, she is doing well and likes participating in the Activity room. Resident 12 appeared calm, compliant with care and followed direction.
During an interview with Minimum Data Set Nurse (MDSN) on 5/4/2025 at 10:36 a.m., MDSN stated MDSN mistakenly quoted Resident 12's MDS assessment with a diagnosis of schizophrenia but they don't have all documentation that supports the diagnosis according to DSM-V (officially known as the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition - a book used by mental health professionals to diagnose and classify mental health disorders). MDSN further stated, Resident 12 is cooperative and does not show any hallucinations, and delusions.
During an interview with the Director of Nursing (DON) on 5/4/2025 at 3:58 p.m., DON stated, Resident 12's needs to meet all criteria before they quote them with a schizophrenia diagnosis on the MDS. DON stated, they need to have a medical professional that will provide the supporting documents.
555786
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555786 B.
Wing 05/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Ocean Park Healthcare 2828 Pico Boulevard Santa Monica, CA 90405
During an observation on 5/2/2035, at 6:49 P.M., in Resident 25's room, certified nursing assistant (CNA) 5 was pushing Resident 25 in a geri chair with Resident 25's feet dragging on the floor and Resident 25's head partially on the head rest and midair.
During a concurrent observation, and interview on 5/2/3035, at 6:51 P.M., with CNA 5, in Resident 25's room, CNA 5 stated that Resident 25's feet were dragging on the floor and Resident 25's head was not comfortable, not fully resting on the chair on one side. CNA 5 stated she was going to reposition Resident 25 so that Resident 25's feet were not dragging on the floor and Resident 25 is aligned in the chair with the head resting on the chair completely. CNA 5 stated she was repositioning Resident 25 because Resident 25's position was not good and Resident 25 may get hurt and the feet may get swollen.
During an interview on 5/4/2025, at 6:47 P.M., with the Director of Nursing (DON), the DON stated that residents need to be properly positioned every two hours and as needed or as indicated when in the geri chair.
The resident's feet should be completely off the ground, resident should be propped up, straight alignment and head of the resident resting on the back of the chair for comfort and to prevent resident getting caught up in the geri chair and getting injured.
555786
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555786 B.
Wing 05/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Ocean Park Healthcare 2828 Pico Boulevard Santa Monica, CA 90405
During an observation on 5/2/2035, at 6:49 P.M., in Resident 25's room, certified nursing assistant (CNA) 5 was pushing Resident 25 in a geri chair with Resident 25's feet dragging on the floor and Resident 25's head partially on the head rest and midair.
During a concurrent observation, and interview on 5/2/3035, at 6:51 P.M., with CNA 5, in Resident 25's room, CNA 5 stated that Resident 25's feet were dragging on the floor and Resident 25's head was not comfortable, not fully resting on the chair on one side. CNA 5 stated she was going to reposition Resident 25 so that Resident 25's feet were not dragging on the floor and Resident 25 is aligned in the chair with the head resting on the chair completely. CNA 5 stated she was repositioning Resident 25 because Resident 25's position was not good and Resident 25 may get hurt and the feet may get swollen.
During an interview on 5/4/2025, at 6:47 P.M., with the Director of Nursing (DON), the DON stated that residents need to be properly positioned every two hours and as needed or as indicated when in the geri chair.
The resident's feet should be completely off the ground, resident should be propped up, straight alignment and head of the resident resting on the back of the chair for comfort and to prevent resident getting caught up in the geri chair and getting injured.
555786
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555786 B.
Wing 05/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Ocean Park Healthcare 2828 Pico Boulevard Santa Monica, CA 90405